277  Treatment Planning with MATRS and ASI

This episode was pre-recorded as part of
a live continuing education webinar on demand. CEUs are still available for this
presentation through ALLCEUs. Register at ALLCEUs.com/CounselorToolbox. I’d like to welcome everybody to today’s
presentation on treatment planning with the matters and ASI now matters is a
different organization of the letters for the acronym smart what we’re talking
about are smart goals and the ASI is the addiction severity index so we’re going
to talk about how to use that instrument to guide treatment planning we’ll
examine how the addiction severity index information can be used for clinical
applications and assists in program evaluation activities so basically
you’re going to see when we go through the ASI it’s a really good tool for ment
for assessing biopsychosocial needs so if you tie those to the treatment plan
then you’re going to be able to see treatment progress we’re gonna identify
differences between program driven and individualized treatment planning
processes I’ve harped on this before going to do it again gain a
familiarization with the process of treatment planning including
considerations in writing and prioritizing problem and goal statements
and developing measurable attainable time limited realistic and specific
objectives or relevant as the other are that sometimes used and we’ll define
basic guidelines and legal considerations in documenting client
status so some of this is going to be a little bit of a repeat from what we
talked about on Tuesday but some of it’s a little bit new so the ASI like I said
is a really good instrument for getting a general biopsychosocial assessment for
someone who’s presenting with addiction issues now it can be co-occurring you
don’t have to have somebody who’s only got addiction because we know that
rarely happens but you know generally a lot of these questions are going to kind
of be geared around somebody with either an addiction or or co-occurring
disorders so they start out with medical status how much has this problem
interfered with your life how much of this problem your medical problems are
due to an addiction and what is your assessment what do you think your need
is for medical intervention and what does the counselor think your need is
for intervention and they this question on each segment of the ASI
why do they ask that because when we’re prioritizing goals we want to identify
the goals that the client is most ready to change the one the clients in at
least preparation if not the action phase of change so you know if I ask
them do you need medical assistance with this and they say no that’s I got it
then that’s probably gonna be down in the priority list unless it’s something
that you know for some reason clinically I feel is really important to to address
for example if they are detoxing from alcohol or benzos detox from either one
of those can be life-threatening so if they say no I’m gonna detox on my own I
might push that issue a little bit because of the potential for severe
outcomes and at the facility I used to work at if they insisted on self
detoxing we had them sign of reliefs basically that they were informed that
detoxing from those either one of those drugs could be life-threatening and it
was suggested that they be admitted to detox so anyway
the next section that it looks at is education employment and finances so
it’s kind of lumping all this stuff together but okay so what’s the person’s
level of education that’s really gonna help us in determining you know what
kind of employment we can steer them to or you know what kind of employment they
might be able to get which will affect what kind of housing they might be able
to get which is gonna affect a lot of things but it can also indicate if they
need to go back to for training or if they want to go back for training and
some people just don’t want to they didn’t like school the first time around
they certainly don’t want to go back occupational history we’re gonna ask
about forever you know what does your occupational history look like since you
started working and for a lot of people they may have a decent occupational
history up until X point when that addiction kicked in and then over the
last 30 days what is your Occupational Outlook kind
of been and I do want to point out with this
that you know the majority of people who have active addictions are full-time
employees they are not unemployed they are not homeless so I don’t want people
to have the misconception that you know the last 30 days we’re expecting it to
be you know a train wreck no you know it can be that they’re getting by it can be
that they’re struggling at work but they still have a job so we want to know what
what it’s been like do they have a driver’s license and transportation
obviously that’s going to impact what kinds of services they can access what
kinds of you know wraparound services they can access if they’re they’re able
to have a job etc sources of financial support you know are you able to
maintain a recovery environment and if you’re familiar with the a Sam one of
the six dimensions that we assess on people is the the adequacy of their
recovery environment we don’t want them to be homeless and coming to treatment
we don’t want them to be living in you know an environment in which there are
lots of drugs or whatever the problem is when possible so we want to look at
their financial support can they even afford to get into an improved situation
do they have dependents maybe we need to bring in some family counseling what is
their perception of employment and financial issues and what is the
clinicians assess need for employment counseling we don’t do employment
counseling you know that’s one of those things that there actually is somebody
out there to do it on like case management so you can refer to your
local Workforce Development Board or one stop or whatever they call it in your
area where people can go get information about potential training resources
potential job openings help with their resume you know pretty much anything
they need which is kind of why they call it one-stop and you can refer out to
there now if you’ve got somebody who is medically unstable who is either
intoxicated right now recently came out of detox they may not
be ready to go back so when we’re talking about prioritizing we need to
look in the big scheme of this person’s recovery what is it that they need and
how could what prep what order do we need to do these things in alcohol and
drug use obviously we’re gonna ask about that so we want to ask about drugs but
we want to expand it a little bit and ask about addictive behaviors we want to
ask about gambling we want to ask about porn addiction we want to ask about any
of those behaviors that are going to trigger that dopamine system and
potentially could cause some addictive consequences how much money did you
spend which drugs or behaviors were most problematic if you’ve had a period of
voluntary abstinence when for how long and how and what triggered the relapse
so we’re getting an idea of the course of what happened and when we’re talking
about these drugs or behaviors most people are poly addicted they’re
addicted to you know alcohol they’re addicted to nicotine and they may have
some behavioral addictions in there you know that’s okay I want to know you know
what is your most problematic drug or behavior which is usually the addiction
of choice and what are the other ones just so we know because if we only treat
this one over here you know if I’ve got somebody who’s addicted to alcohol and
occasionally uses LSD and marijuana and is addicted to online gambling if the
only thing I address is the alcohol addiction we got these other ones out
here that are just prime to create a relapse scenario so we need to make sure
that we’re aware of what’s going on if they were abstinent if they were clean
for a while great when was that you know was it 15 years ago or was it
last month how long did you stay clean that’s good information to know if they
stayed clean for a week okay well they had some tools that help them to stay
clean for a and we can build on that if they stayed
clean for six months well all right what changed what triggered the relapse how
did you go from having six months clean or six years clean to relapsing that
gives us information we need to develop that relapse prevention plan and to
develop the treatment plan I mean if we find out that Jim Bob was doing fine for
four years was you know go into meetings was had a full time job and then all of
a sudden he got laid off and his wife left him
okay well that gives us an idea about areas that we may need to assist Jim Bob
with employment and with some grief counseling and maybe some relationship
counseling you know figure out what happened there help him come to terms
with that loss you know I don’t know but you know that’s gonna be very different
than somebody who comes in who’s never been sober before and has no idea where
to even start with sobriety we want to ask about a history of medical problems
due to use now you already asked about that in medical but they asked about it
again we want to ask about treatment history
why do we care and too often I see clinicians skirt over this and it’s so
there’s so much information you can get from this when you were in treatment
what helped you know oh my gosh we rarely ask that question we just ask
okay when were you in treatment where was it who was your primary okay what
where else were you in treatment stop ask what helped when you were in
treatment what did you learn what was useful but also what was not useful
because every treatment program people go through there are gonna be parts of
it that are really useful and parts of it they’re like I have no idea why I had
to do that so we want to ask because that helps us again learn more about our
clients and what’s going to work for them when we get to treatment planning
we want to focus on doing those things that already worked and not redoing the
things that didn’t work and it could be that you know the approach that was used
was not a good fit it could be that the
clinician was not a good fit you know maybe it’s a skill that this person is
going to develop eventually but it was just not a good fit with the clinician
so we want to explore that a little bit in order to give us the best chance of
getting the best initial treatment plan and then we want to ask about their
perception of the need for treatment right now what kind of treatment do you
think you need outpatient intensive outpatient residential what is it that
that you need and then we’re going to put our two cents in and obviously if
again if you’re familiar with a sam you’re probably going to do the a sam
here in order to determine the appropriate level of care that we’re
going to recommend now I’ve had a lot of clients that have scored for residential
treatment but have said you know what no I can’t for whatever reason they can’t
they’ve got three kids at home and nobody to take care of them they can’t
afford to lose their job right now there’s a whole myriad of reasons why
somebody might not be able to commit to 30 60 90 days in residential treatment
so we want to say okay you know how can we work with you if you can’t do that
what can you do and we also want if they say I don’t need residential it’s not
that bad okay you know and and sometimes you can share depending on your rapport
with the client you can share your opinion about why residential would be a
better or IOP or whatever it is would be a better choice but ultimately it’s
their choice and I tell them I’m more than happy to be proven wrong if you can
handle this with intensive outpatient or outpatient that is awesome and some
people just want to do like a couple of times a week outpatient and self-help
you know that’s their call legal status we’re gonna ask about if they’re on
probation and parole if treatment is court mandated if it is there may be
some requirements that they have to go to some level of treatment and if so
okay I remember when my first job out of at school I worked with felony probation
and parole and for those of you who are Trekkies you’ll understand this for
those of you who’ve never watched Star Trek it’s not gonna it’s not gonna hit
but I was working with these clients and you know I was in there and I was trying
to do the curriculum and we were gonna work on relapse prevention and we were
going to work on this and I was going through this rigid curriculum that we
had set up and they just were falling flat
and so I went to my supervisor and I said mark you know I I’m doing the
curriculum and you know I’m trying to be entertaining and everything and it is
you know a six o’clock at night group but it’s just we’re not going anywhere
and they sit there and look at me like I’ve got three heads the whole time and
he said show them and I don’t remember the name of the episode but it’s the
Star Trek with the Borg in it and I looked at him quizzically and thankfully
this one he didn’t make me figure out on my own but he was like resistance is
futile they are on what we call on papers when they’re on probation and
parole they’re on papers right now and if they want to get off papers they need
to get with the program so you know and we talked about what it meant to be feel
like you were being assimilated in the next group and it became a decent
therapeutic activity but I also switched my approach at that point you know we
talked a little bit about what they wanted to get out of treatment and most
of them that were in there just believed they didn’t need treatment
they were dealers it wasn’t their stuff you know whatever and so instead of you
know continuing to hammer at something that they didn’t think applied to them I
said okay let’s talk about what does apply to you you’re stuck with me for 12
weeks what does apply to you so when you’re
working with court mandated clients you really want to find out what they’re
motivated to work on and if their only motivation is to not have to see your
face anymore well then you lay out this is what you got to do to not see my face
you know pretty simple we want to catalog charges and frequency
and this is one of the easiest ways of determining whether somebody meets
criteria if you will because generally they say two or more problems in a
six-month period related to the addiction well if you pull out their rap
sheet and it’s you know six pages deep of possession possession with intent use
public intox whatever even if they weren’t convicted we want to look at how
many charges there were and you want to look at charges that were addiction
related and then other charges that were there that you know the person may have
been under under the influence when they were robbing a liquor store or whatever
ask them how many times they’ve been incarcerated how many days in the last
thirty they’ve been in jail what their perception of their legal problems are
and do you think they need legal services and counseling legal legal
counseling some charges can be expunged after a period of time which helps
people get jobs some people will need a little bit more assistance transitioning
to reduce their recidivism rate the family and social history we want to
identify the history of addictions or psychiatric issues in first and second
degree family members why because this lets us know what may be going on with
our client that may or may not have been diagnosed yet so we can keep an eye out
marital satisfaction and status or marital status and satisfaction you know
if they’re single and they’re happy with it cool if they are married and they’re
happy with it cool if they are in a dysfunctional relationship and they’re
not satisfied then that could be a stressor that could be causing all kinds
of mood issues and predispose them to a relapse so we want to talk about that
what is their what are their living arrangements and their satisfaction with
it so again this goes to that a cm dimension of recovery environment where
do you live with whom do you live is it safe
that means you know are you constantly being exposed
to addictions and drugs and chaos and all this stuff
or is it an emotionally and physically safe environment does anybody use
alcohol or drugs in the household even if someone is an alcoholic for example
or addicted to alcohol okay you know and everybody else in the house is using
crack cocaine it doesn’t mean that that’s safe that just means the other
people are not using that person’s addiction of choice but they’re still
using and they’re still using mood altering substances in front of the
person with whom do you spend most of your time and who are your close friends
we want to ask this because this helps us identify social support and this also
helps this identify anything we may need to help the person with in terms of
interpersonal effectiveness skills have you had serious difficulty getting along
with any first-degree family member co-worker or friend again identifying
any interpersonal skills deficits that may need to be addressed trauma and
abuse history in the assessment and y’all probably notice and the same thing
is true with the ASI we don’t go into you know a deep dive on this we just
want to know if there’s an abuse history and you know maybe the general idea if
they were raped or molested or something but we don’t we don’t want to go into a
deep dive because it’s not a psychologically safe place right now and
and sometimes it’s important to help them put on the brakes when when they
start going into that because you don’t want to precipitate a crisis before
they’re even you know in a good rhythm and services and have good rapport with
somebody but we want to ask about this not only because it will probably be an
issue we need to address but because we want to make sure that we are operating
from a trauma-informed perspective and we don’t reach Ramat eyes the person so
if we find out that they have a history of verbal abuse you know they’re one of
their parents used to just scream at them and berate them in front of people
all the time well we want to make sure that heaven
forbid your staff should ever do this but we want to make sure that never
happens that you know somebody doesn’t yell at them or talk to them in a loud
voice and it could be staff or it could be other clients but if other clients
you know do raise their voice then we may need to intervene more quickly than
maybe maybe with somebody else so again what’s their perception what’s your
perception this will give us an idea where to start with treatment
psychiatric how many times have you been hospitalized for psychiatric issues
schizophrenia suicidality homicide allottee any of those the number of
times ever and over the last 30 days have you experienced depression anxiety
hallucinations cognitive difficulties and suicidal ideation so it goes down
kind of the laundry list of the big ones and we want to separate hallucinations
that are drug-induced from hallucinations that are not because that
can also indicate that there may be some early onset dementia there may be some
alcohol-related dementia there could be a lot of reasons
Parkinson’s also sometimes people with Parkinson’s have hallucinations so it’s
important to be aware of these things that may need to be addressed are you on
or have you ever been on psychiatric meds perception of psychiatric issues
and assessed need for mental health counseling I have yet to work with a
client who is presenting with addiction issues
who doesn’t have some concurrent mood issues now whether you want to say
whether it was a long-standing depression or buy anxiety or something
you know not necessarily but as they start to sober up or come out of their
addiction or get ready for change they often hit a crisis period and their
anxiety and depression often increase so a lot of times clients do have some
pretty pressing grief trauma depression or anxiety issues
that need to be addressed but we also want to look a lot of there’s a high
correlation between substance misuse and ADHD as well as you know the mood
disorders so we want to look for some of those things and fetal alcohol spectrum
issues as well okay so we’ve done this asi we’ve gotten a
ton of information probably spent an hour longer in the assessment than we
were supposed to that was me the assessments conducted data and
information are collected from the client and then we have to go out
theoretically and collect information from collateral sources probation and
parole criminal history family members if we have the release and any
assessment scales that you used like the sassier whatever problems are identified
readiness for change for each problem is identified so we go through that ASI and
in each domain you know we’re going to sit down with the client go okay it
seems like in this domain you’ve got these pressing issues and we’ll write
down all those issues and then I’ll give the client a piece of paper and I’ll say
okay rank them from 1 to 8 which ones most important and which ones next to
next most important and if there’s a tie that’s ok we can have a couple of twos
in there or something but I want you to tell me in your perception what do you
think is the most important thing to work on right now so we’re prioritizing
these problem statements and then we create the goals and we go through each
one and usually I stop my treatment plans we only address two or three
problems at one time addressing more than that is just overwhelming even if
the clients in residential so I say okay for these three problems that you’ve
identified is the most important what will it look like when they are resolved
this is how we stay our goal you know what are we working towards how are we
gonna know when you’ve achieved recovery that’s that’s far too vague objectives
to meet the goals are defined remember those steps we kept talking
about recipes on Tuesday I got hungry quite frankly but we want to identify
what do you need to do first then what do you need to do and then what do you
need to do interventions are revised or changed based on client response to
treatment so we’re gonna choose those interventions what we do based on the
client’s response treatment plans are developed at admission and continually
updated this is a pet peeve of mine it’s continually updated we don’t just
do it when the client comes in and then sign off on it when the client leaves
treatment plan should be guiding treatment just like a recipe guide
you’re cooking you don’t look at it and go okay I got it and put the book away
you keep consulting back you do a step then you say okay what’s the next step
and then you do that step and you go back and say what’s the next step that
helps the person keep moving forward it helps the person learn how to set goals
it helps the person see incremental progress which is empowering to them
treatment plans are individualized so even if I have two clients that have the
same presenting diagnosis they’re probably not going to have the exact
same issues or treatment problem statements are non-judgmental and not
jargony we want to avoid terms like denial or resistant or codependent we
want to identify what the client is doing or not doing goals must be
specific measurable so use as evidenced by client will achieve recovery you know
that’s kind of vague as evidenced by being abstinent from substances for a
minimum of 30 days by you know and I usually put three or four things in
there that we can mark off they’re achievable we want to make sure the
client can do it in the time frame that we’ve got you know some some goals are
going to be achievable to years down the road but that’s not appropriate for this
treatment plan if your treatment plan is third
days then you’ve got to put things that can be achieved in 30 days who figured
so it’s important to make sure that you keep your goals and your objectives
small and incremental so the person can when they finish treatment or graduate
or whatever you call it in your place they can go I’m done
I did that they’re the goals are relevant so again make sure anything
that you’re going to have the client do you can tie back to their presenting
issue and this is true not only to help the client stay motivated but also to
help the referral sources feel like they’re getting what they need and for
insurance reimbursement program driven plans are
one-size-fits-all they reflect the components and/or activities and
services available in the program and the first place I worked it was a
program driven and I didn’t know any anything different it was a program
driven plan clients would come in and we had a we had groups six hours a day
every day and each group slot we had two different groups so you could choose but
that was his program that was as individualized as it got clients had one
individual a week and they had six hours of group a day and then they went to
12-step meetings four times a week that was it everybody did that there was no
smart recovery there was no pastoral counseling there was no none of that
it was here’s our program will plug in well you can see why that might not work
for some people we did have one client for example who had a very very bad tic
disorder and the more stressed he got the worst his tics got and he had super
high social anxiety so being in front of people being in groups
he couldn’t even function and so you couldn’t call on him because he would
just get really upset and couldn’t speak he couldn’t eat in the lunchroom
because eating in front of people was too stressful for him and his tics would
get so bad he couldn’t get his hand to his mouth and you know eat effectively
so we had to obviously work with him but unless something was glaringly obvious
or reflected something more like a disability a lot of times the program
didn’t adjust to people’s individual needs so you know that’s a program
driven plan it’s a good plan it works for probably 60 70 percent of the people
but the other 30 percent fall through the cracks individualized plans are
sized to match client needs not all clients have the same needs or in the
same situation so we need to figure out their needs are the individualized plan
is made to fit the client based on his or her unique abilities goals lifestyle
socio-economic realities work history educational background and culture and
for example in this treatment program we did a lot of big book work and we did a
lot of worksheets and we did a lot of reading intensive
stuff well you know what 10% of our clients couldn’t read so that’s a
problem and you know we had to figure out how to adjust to help them out but
we need to focus on that we need to appreciate their cultural backgrounds
and their lifestyles and you know fit again fit their goals why are you in
treatment what are you hoping to get out of it when treatment programs don’t
offer services that address specific client needs referrals to outside
services are necessary so in that program that I worked in you know
sometimes we just didn’t have the services to meet all the client’s needs
so we needed to refer out to the VA or to other providers or that would have
been ideal so what components are found in a
treatment plan problems identified during the assessment and you know
obviously that’s where we’re gonna start is the problem statement goals that are
reasonably achievable in the active treatment phase so wow they’re with you
the term objectives in the ASI format and ASI has their own treatment planning
sheet and everything if you want to use it but in the ASI format the term
objectives is defined as what the client does to meet the goals and the term
intervention is used as what the staff will do to assist the client so remember
on Tuesday I said the term objective and intervention gets a little wonky because
it’s defined differently in different places this is one of those examples but
so here again the objectives are what the client is going to do and the
interventions are where we how are we going to help them how are we going to
facilitate so prioritizing problems you will
recognize Maslow’s hierarchy and you know I love Maslow’s hierarchy generally
we want to stabilize biomedical conditions
acute intoxication any withdrawal issues and don’t forget protracted withdrawal
please protracted withdrawal can happen two to four weeks after the person
actually stops using a substance and some of you are aware of
pause post acute withdrawal syndrome but that refers to protracted withdrawal
benzodiazepines alcohol methamphetamines and cannabis are for that you can
experience protracted withdrawal with so we need to make sure that the client is
again safe in terms of any issues that may come up because their cravings are
going to get really bad again it’s gonna they’re gonna be really bad then they’ll
get better for a while and then during that protracted withdrawal they’re gonna
start really Jones and again nutrition we want to make sure that they’ve got
the stuff they need to start helping their body and brain heal and we want to
address any concurrent health issues if you’ve got somebody who is in just
immense amounts of pain who is malnourished who is not sleeping and has
HIV you know they’ve got a lot of other stuff going on they’re not going to be
as focused on the rest of it so then we move up to safety their recovery and
living environment suicidal ideation now you know I personally would probably put
suicidal ideation down on the lower level but you know we’re talking about
the hierarchy here their ability for self-care relapse potential continued
use potential functional impairment and legal issues can they do activities of
daily living sufficiently to be safe and to maintain a roof over their head and
you know the bare minimums once they have those sorts of things they’re
they’re safe they’re comfortable they our healthy ish or on the way to being
healthy then we can start working on interpersonal skills but up until then
they really don’t feel well or they’re exhausted so we want to help them figure
out how to get on a good footing so they can focus on these more esoteric things
so what do we do with goals like I said recovery is not a specific goal
that’s just how do I know if somebody’s in recovery what does that mean that
means something different for every single person out there when a goal is
specific the person can objectively evaluate the data to determine that it’s
been achieved and anybody can they can read this and go yep Sam did that or no
no he didn’t he didn’t meet that goal so what problems are you experiencing as a
result of your condition and that’s what the ASI really asks about a lot so in
that medical section for example if they’re experiencing high blood pressure
or insomnia that would go in there down in the family section relationship
problems in the psychiatric session depression and then in the educational
financial section you know job loss those are all things that could be
identified as current problems as a result of their condition whether it’s
depression or or addiction or both how will you know when each of those
problems is resolved measurable and I know I hoped on that on Tuesday blood
pressure if we’re talking about you know those goals we just stated blood
pressure will be 135 over 80 or better I will be able to sleep restfully at least
seven hours each night at least five out of every seven days I won’t get into
fights with my partner at least five out of every seven days I will rate my
happiness as three or better and I will acquire a job that pays at least fifteen
dollars an hour so those are all very specific goals now I don’t think a
person could achieve all of these goals in 30 days they were just kind of
examples to show you measure ability and specificity measurable means a third
person can look at the day and say yes or no so when we’re talking
about behavior we want to look at frequency of the new behavior I went to
work five days this week I was free and not incarcerated twenty two out of the
last thirty days or whatever whatever we’re looking at or we can look at the
number of times per day that somebody used a positive coping strategy or
practiced mindfulness or whatever we can look at measuring intensity and a lot of
times we use an anchored Likert scale and why do we use anchored because if
you just say on a 1 to a 5 people are gonna be like eh
and it Wiggles even the same person may rate how they feel it the same way a to
one day and a three the next so give them words or pictures one extremely
depressed to moderately depressed three is content 4 is happy and 5 is elated
you know I try to use different words instead of just saying less depressed
and not very depressed in order to give them something to kind of latch on to
and go ok do I feel content or less than or do I can feel content or more than
you can also use a for point like Likert scale in terms of confidence you know
how confident are you that you can accomplish this goal or whatever none
that’s a 1 I’m a little bit confident number 3 is I’m feeling confident and 4
is I got this make sure they have those anchors because that’s you know it makes
it more real if they have words to put with it not just numbers and they’ve
shown that it really helps increase validity and reliability the other thing
you can look at remember frequency intensity or duration for duration if
we’re talking about a panic attack you know it will resolve within 5 minutes or
10 minutes but a child’s temper tantrum will resolve within 5 minutes
the urge to use will pass in less than 30 min
it’s grief you know a grief episode will pass in less than 30 minutes
what however they want to identify it but if they are you know just oppressed
with grief right now and you know 15 hours a day they are crying and grieving
they’re going to continue to have some grief episodes but if those grieving
episodes when they have a memory that triggers a grief reaction if it only
lasts 30 minutes as opposed to three hours that’s some really good progress
you can also use numbers list 10 examples of you know that gives you a
way to measure or identify things and you can use scales now we don’t don’t
often use scales in community mental health but you can the Brecht Beck
Depression Inventory will drop two points for example and there are other
scales that are out there that you can use and regularly retest the person to
see if they’re improving you know that’s your that’s your call the goals are
achievable and attainable what can the person realistically do in the given
time can they enroll in school can they get a job can they stay clean for 30
days can the person get to the point of raiding their mood as a three remember
which is content or better on the depression scale five out of every seven
days that’s it that’s a big ask so you want to make sure the person can achieve
whatever goal it is increase the frequency that unhelpful thoughts are
identified and effectively disputed at least 70% of the time you’d have to find
a way to kind of log this with hash marks or something but there are ways
you can do it it has to be relevant objectives need to clearly relate back
to goals which need to clearly relate back to the reason why the person’s and
treatment anyone reading the plan must be able to easily understand why each
objective and intervention are there you know if the auditors come in and they’re
reading this and they see something about you know is going to go bowling
every sad des excuse me why and yeah that was a
goal we are an objective we used to have in our residential treatment program
because a lot of our clients either never knew how or had forgotten how to
have fun clean and sober so bowling was something that they could do to get out
of the facility and to have some fun and they were clean sober and safe so we
related it back it was part of their recreational therapy but you know just
seeing that you want to know why why are they bowling in the goal statement after
the as evidenced by ad the statement this is important to my recovery because
so this is important to my happiness this is important to my sobriety this is
important to my whatever this end goal is because so if the goal is to get get
a job that pays at least fifteen dollars an hour okay this is important to my
recovery because and it’s time limited all goals need to be completed within
the treatment period and objectives need to be constructed so they can be
completed for children through fifth grade which you know we’re not going to
be using the ASI with them but just in general for children through fifth grade
daily they need to have that feedback regularly because I mean think about how
little they are and think about how much time they’ve been on this earth a whole
day is a long time compared to how long they’ve been on the air so they need
that reinforcement daily for youth 12 and up weekly and you can use a star
chart with them or some kind of a token economy which works really well but
generally the reward is only once a week documentation plans are constructed with
the client and clients get a copy of their plans clients cannot follow a plan
if they don’t have it so you need to make sure they have a copy why is this
important well number one it gives relevance to why we wrote it number two
it helps the client because they worked with you to develop it so it helped them
learn how to start setting goals that are achievable but then it helps them
follow through the process if they’re following it and they’re marking off
those steps they’re going to achieve their goal and they’re going to feel
empowered by that it’ll also help them see incremental progress you know
they’re going to look back and go wow I’ve already marked off 15 things well
great progress notes if it ain’t written that didn’t happen or I’m sorry if it
isn’t documented it didn’t happen um we all know this but we can get a slack
sometimes when we’re pressed for time so remember to figure out a way to write
down your notes one thing that I’ve shared with you guys
that I do in when I’m doing groups is I have everybody complete and exit sheet
for the day so they write down you know there’s a checklist that assesses how
they’re doing if they need anything if that when their next appointment is with
their individual therapist and what what is one thing you got out of group today
so I have them write that down that way I collect those and you know have
something written in the clients handwriting and then I go through
there’s another section on that same sheet that I can do a mini Mental Status
exam you know what’s the client oriented you have future plans yada yada
I can mark it off right there before I even like go back to my desk I stay in
the group room and I mark that off that way it’s easier for me to write my notes
when I get back to a computer notes are dated signed and legible client name and
identifiers are included on each page referral information has been documented
sources of information are clearly documented clients strengths and
limitations in achieving goals are noted and considered so as the client goes
through you know if we see that they’ve got some strengths that are really
helping them in one area you know we want to note that and if we see that
they’re struggling in another area maybe they’re struggling to get a job because
of their social anxiety we want to note that because we’re gonna probably need
to modify the treatment plan to help them deal with their social anxiety
before they go out and start applying for jobs again entries should include
the clinicians professional assessment and continued plan of action always end
your notes with you know well our notes used to have the the status exam at the
top what was done in session you know generally and then you know worked with
client in individual counseling or work with client in codependency group and
then addressed problem one a bla address problem three C and we talked about how
we addressed each objective and that was the way Medicaid required us to do it
that each treatment plan or each progress note specifically identified
which objective of which problem or problems were addressed in that
particular session so it helped keep us you know organized and then at the end
we had the for next week client will or client will continue doing so there was
clear communication about what the next steps were and and yes Jason I agree I love to have
client notes in the file not only because it empowers them and it makes
the file less mysterious but it also a deters love to see that so they love to
see that we’re really involving the client in this process and we’re paying
attention we’re not just having them come into group and then leave and going
well hope they got something out of it we’re really honing in and making sure
that everybody’s getting something so progress notes client review sheets can
be helpful for individual and this is what I use and you can complete at the
end of the session with any client identify the problems and objectives you
worked on this week so you’re gonna have a couple of sheets here problem number one objective-c did you
complete it yes or no if not why not I will generally fill this out as we’re
talking you know and I go through why because I want the client to remember
what they did I also want to get my progress note done but you can go
through this and it just kind of is a big summary of what we talked about in
session for the client what help do you need with this objective if any was it
useful yes or no if not why not so help me understand so we can modify your
treatment plan what else could you do to address this problem that would be more
useful so sometimes clients you know are
supposed to be going to 12-step meetings and some clients it just doesn’t work
for them it doesn’t click for them so did you go to your meetings yes was it
useful No why not and they can tell you why not
then you can ask what could you do to address this problem that might be more
useful and they might say smart recovery or celebrate recovery or women in
recovery there’s a lot of different options besides just 12-step groups that
people can explore if 12 steps don’t necessarily work for them but we want to
make sure instead of saying well just keep going and eventually it’ll click
there a lot of times they get frustrated and they drop out so we want to make
sure if they say this is not working for me we figure out why it also could be
that the group they’re going to is a bad fit because sometimes there are a lot of
young people and very few old timers in the meetings or sometimes they’re the
new person and it’s almost all Alzheimer’s and they feel out of their
element sometimes the meeting is too big and they do better in big book studies
as opposed to the large meetings so figure out why it didn’t work and then
address from there it doesn’t mean you have to scrap the whole thing you may be
able to make some modifications and then ask the client what problems and
objectives are you going to work on over the next week by having
them tell you and having it come out of their mouth it reinforces it in their
mind so they were it’s easier for them to remember over the next week I am
going to do my mindfulness checks at every meal I am going to go to my
doctor’s appointment whatever it is you’ll drop that down but they’re
reiterating it and anything they forget you can point out and put in then give
them a copy of it so this is their go by a guide this is their plan for what
they’re going to do I haven’t yet had a client get upset about going through
this going why are we doing your paperwork right now because I make it
relevant to them because when they are setting and achieving their own goals
not in counseling they’re going to probably do something similar and they
may not write as much down but they’re going to have to go through it
incrementally so this is a learning process so progress progress notes
subjective the clients observations or thoughts and the clients direct
statements they talk about what they felt what was going on for them it’s
object the objective part is our objective observations during the
session if you must use a subjective term like withdrawn follow it by with as
evidenced by because withdrawn you know does that mean the person was had poor
eye contact wasn’t talking you know what did withdrawn look like for this client
so be as objective as possible so anyone reading the note can understand what was
actually going on complete a mental status to orientation memory in language
and I always suggest future plans that’s one of the better indicators of
suicidality if people are refusing to talk about future plans that’s a huge
red warning flag a stands for assessment of progress which identifies each goal
and objective worked on and the outcome and P stands for plans for the next
session some places use the soap format so this is what you would do to other
formats adapt is described or the data assess what is your assessment of
situation and P is what is your plan I haven’t worked at a place that likes the
DAP format but you know some of your places may and burp is behavior what
behaviors did the clients evidence what interventions did you use or did he or
she use over the past week what was their response to the applied
interventions if you gave them homework over the week to address unhelpful
thoughts that was your intervention what was their response to it and then what’s
your plan to help them continue to address that behavior cart I promise
we’re almost finished with these these are really helpful for interns to help
them remember what to put in their notes cart stands for client condition so
that’s your mental status orientation suicidality a is what action did the
counselor do in response to client condition r is client response to
treatment plan so what did they do over the week how are they progressing toward
their identified goals and T is how does their response relate to the treatment
plan so if their response is good then the treatment plan is going to continue
if their response is poor then we’re going to make adjustments to the
treatment plan and we’re going to talk about what adjustments are going to make
here and chart is the client condition but then we also add the H which is
historical significance of the client condition so one client I worked with
for example every time he would get out of treatment he would be doing really
well and then he’d get in a relationship the relationship would end and he would
relapse it was like clockwork I’m every time he broke up out of a
relationship he relapsed so client condition if if he came in and he said
I’m in a relationship you know I’m like okay we’re in this honeymoon phase
historical significance even if they haven’t broken up yet I’m going to be on
high alert for or trouble in paradise because I know
that that can lead to a relapse and I’m gonna obviously make sure that that
client is aware and and putting in place stopgaps a what action did we do in
response the client condition so we can make the client aware of any concerns or
any trends you see our what is the clients response to the treatment plan
and T how does the response relate to the treatment plan so again those are
just different ways you can figure out how to get stuff in your notes
I like the soap format better than any of the others but you know your agency
may be a little different the addiction severity index can be used
for clinical applications and assist in program evaluation activities because it
assesses multiple domains of functioning which can be linked to Maslow’s
hierarchy so it really gives us a lot of really good information that we can say
is this a problem for you right now and how motivated are you to work on it
program driven plans fit the patient into services they just plug and chug
individualized plans fit the services to the patient so this is more like a
smorgasbord treatment plan goals and objectives should be positive so we want
to add something to people’s life we want the to help them move toward
happiness not be less depressed they’re specific measurable attainable relevant
and time limited it’s important to tie the treatment plan to the assessment and
the interventions and client progress to the plans so we want to make sure that
anybody who’s reading this plan could understands why is the action being
taken how does it benefit the client in achieving his or her goals what was done
this past week include client activities and referral contacts you know we want
to make sure that it’s clear in the chart how the client is progressing you
can give them a great treatment plan and if they stay on problem 1a for the
entire 60 days it’s going to be a problem
so we want to make sure that we’re charting forward progress what was the
clients response to those activities so they’re on 1a and they’re stuck well
stuck is the response so we need to look at why they’re stuck and what to do
about it what are the plans for next week and what referrals were made if any
so we want to make sure we get those in there and I know there’s just so much to
do and we do what we do well most of us I think I shouldn’t speak for everybody
but most of us do what we do because we love working with clients and helping
people and we love the interaction part most of us detest the paperwork part
some people do it they don’t hate it but it’s not their favorite but a lot of
people detest it and I get that there are like I said there are ways you can
use check sheets get client feedback get client exit response sheets to get
client feedback so you’re not trying to have to scratch your head and go hmm
what did I talk about with that client at nine o’clock this morning and you can
get it done in session so it’s just bada-bing and if you make it a matter of
course that you’re doing this at the end of session and you help the client see
how it’s integral to helping them then you know so much the better there are
additional videos on our YouTube channel I’ll see yous education there’s one on
treatment planning another one on treatment planning using clinical
history to identify motivation and reinforcers goal-setting and motivation
and then there’s a whole series or playlist on behavior modification so if
you’re working with interns or students that need assistance with any of this
please feel free to you know tune in to some of those videos they might give
them some helpful tips anybody else have any questions all righty everybody as you can tell I
really love talking about treatment planning I like writing them too that’s
the one piece of paperwork that I actually enjoy so if you have any
questions feel free to message me and we will go from there we’re going to switch
gears next week and do a series on infant working with infants and toddlers
with developmental delays and I believe that’s four sessions and then after that
we’re going to go into individual and group activities for addressing
depression you all righty everybody well you know I see
Jason’s gonna be out next week so that’s a bummer and if any of the rest of you
are going to be taking vacation before the fourth of July I will miss seeing
y’all in here but I will see you after the fourth if
that’s when you come back everybody else I’ll see you on Tuesday
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